august 23, 2002

although I'm new at the doctor thing I've been around enough misery in four years of training that I'm generally not bothered by it. today I was bothered and I can't stop thinking about it so I'll write about it - then it won't be a problem, it will be an essay. I had just finished telling the parents of a six year old about the cast we put on his broken arm and I walked out of room C and into the center of the montreal children's hospital emergency room, and immediately I knew something was up, but I didn't know exactly why I knew that, and a moment later realized that all the staff had disappeared. As I was digesting this, the lone remaining nurse told me that there was a trauma in the crash room, a place reserved for patients who have to be seen immediately. This patient, whose name I never knew and will never know, certainly met that criterion. I walked in and found twenty people in various states of motion and confusion surrounding and obscuring a bed. One of the paramedics/offensive linemen moved away, leaving a nice hole for me to slip through so that I could take my place at the foot of the bed. The first thing I noticed was my boss, Dr. Owen, at the head of the bed barking orders at nurses. Dr. Owen is a 60-something year old overweight surgeon who spends most of his time operating on adults, but picks up the occasional shift in the children's surgical ER which is 95% simple fractures and lacerations, with the occasional appendicitis. A family man who spends the entire shift making sure he can go home on time, Dr. Owen wears khakis and a plaid button-down and looks more like a bureaucrat than a physician. I don't remember what he was saying, but his furrowed brow told me that the situation had forced him out of his usual nonchalant approach to emergency medicine. Then I saw her face, she looked about 11, wearing a rainbow pastel tank top and black, knee-length shorts with a red stripe down each side. She was moaning, and I thought she was moaning words, but there were too many people talking to know. Next I saw her right leg, which was bent at a place where it's not supposed to be bent, and at the fulcrum of this inappropriate joint, a bleeding wound, an open femoral fracture, probably a pedestrian-automobile I thought. Then I saw a doctor who wasn't there before, whom I recognized as the senior pediatric surgical resident (why is surgery down here?) pulling away the rainbow pastel tank top that had just been cut through with shears and very aggressively twisting her right nipple. Her moaning continued, but did not change its pattern or intensity, and she wasn't moving in response to this very painful stimulus and then I realized that her moans weren't the reassuring moans of pain and felt nervous. A new doctor was at the head of the bed, he was Kevin the neurosurgery resident who's on call every night during his pediatrics month, wow neurosurg is already here, too. He had taken Dr. Owen's place and yelled out, or at least I think he was yelling, "Left pupil dilated and fixed." At the same time Dr. Owen, now invisible, screamed "can we get a set of vitals?" To which a nurse, who was fitting a pulse oximeter to the patient's left ring finger, retorted, insulted, "I'm working on it." Kevin shouts again, "Right pupil dilated and sluggish." All this was hitting me like slaps across the face, I had been standing there about a minute, and then she raised up her outstretched right arm into the air, and another nurse who was trying to put an IV into the hand at the end of that arm cursed, and Kevin says smoothly but with wide eyes, "She's decerebrating," which was the slap that hit me the hardest. I've come across the concept of decerebrate posturing a thousand times but hadn't ever seen it, and I think I assumed I never would. I'm deliberating about the ramifications of this development, which I understand to be a step in front of braindeath, when yet another doctor, this one blonde, assumes control and declares that he's going to intubate the patient. Dr. Owen, as if seconding the motion, says, "The ICU fellow is going to intubate!" I now realize that every resident in the hospital knew about this girl before I did. They start pushing drugs into her, and the room becomes quiet enough for me to wonder if I'm going to be called upon to do anything. I look around and see at least a dozen doctors, of which I'm the most junior, and am both disappointed and relieved. Serious pediatric trauma is unfortunately a rare thing, so when it happens the experience is gobbled up by the senior residents. My ambivalence is broken by mom, who suddenly appears at the bedside. She's in her thirties, dressed like a mom. She has long curly blonde hair and a numb expression on her face, she's shellshocked. She sees her daughter's eyes tearing and she mumbles, "Is she crying?" I think I'm the only one who hears, but I'm at the other end of the bed, which might as well have been a hundred yards away, and don't know the answer to her question besides. She looks up and says to the blonde ICU fellow, "Is she crying?" I imagine the ICU fellow to be thinking about any number of things as he tries to visualize an eleven year old set of vocal cords, but whether or not the patient attached to those cords is crying isn't among them. Still, he says, "No - she's gotten thio and roc." This doesn't seem to answer mom's question, and I feel like I'm the only one noticing this, so I clear my throat and shout at her, "She's paralyzed and sedated," and immediately regret saying it. Mom looks horrified. Her lower lip starts to quiver. She puts her hands over her mouth. Someone yells out vital signs. Mom takes a step back from the table, looks like she's going to fall, but doesn't. She looks around the room and sees me staring at her, an obviously inappropriate thing for a doctor ostensibly attending to her daughter's massive head injury to be doing, so I turn my head and gaze at the nurse placing the second intravenous line, while trying to look at mom using my right ear. The surgeon addresses me: "Hey! Call radiology, tell them CT head and CT abdomen no contrast NO ARGUMENT." I walk out and tell the clerk to page radiology while I prepare for the argument, except that I don't know what the argument is. What were they going to argue? Fuck I don't even know what happened to this kid. I decide that if radiology gives me any lip I'll just say, "She's decerebrating!" I walk back into the room, and there's dad. Dad is about 40, with medium length but somehow spiky hair, wearing black slacks that are too small for his waist, giving him a bit of a humpty dumpty look. He's pacing a circle around mom, who's trembling with her whole body, and she seems to somehow be cowering from him, which confused me, and I just stopped in my tracks and stood there, far enough away from the scene to be inconspicuous.

"FUCK!!!" Dad screamed, and I jumped. He was responding to this situation not with grief or anxiety but with anger. "FUCK!!" and he stopped pacing and looked at mom with furious eyes. "How could you let her cross the street alone!!! FUCK!!"

I think my jaw literally dropped. I grabbed onto a counter to steady myself. He was attacking her. Their daughter was dying 10 feet away and he was shouting at mom, blaming her, as she backed up against the wall and covered her entire face with her hands to mute her sobs and to protect herself from the spittle flying out of his mouth. The clerk, a trendy 22 year old girl named Marie-Laurel, must have been calling me because she grabbed my arm and pulled me back into the ER. She shoved a phone in my ear, and I spoke with radiology, but I don't know anything I said, I only recall the feeling of the back of my neck getting hotter and hotter, and, I don't joke, looking around the room for a weapon to use on dad. I remember thinking I wanted a bat and deciding that there were no bats in the ER and what's the closest thing, and looking at the leg of the chair Marie-Laurel was sitting on and thinking that might work. I cautiously walk back into the crash room and it's deserted, she was in there for no longer than 10 minutes. The only person left in the room, a nurse writing on a clipboard, sees my blank expression and tells me they went up to CT.